<?php
require_once 'config/config.php';

if (isset($_POST['etablissement'])) {
//# établissement
    $sql_etablissement = 'INSERT INTO etablissement(etablissement, adresse, code_postal, ville, connaissance) VALUES ("' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '", "' . $_POST['connu_site'] . '")';
    mysql_query($sql_etablissement) or die(mysql_error());
    $id_etablisssment = mysql_insert_id();

//# contact administrative
    $sql_contact = 'INSERT INTO contact_administratif(id_etablissement, nom, prenom, fonction, telephone, email) VALUES ("' . $id_etablisssment . '", "' . $_POST['nom'] . '", "' . $_POST['prenom'] . '", "' . $_POST['fonction'] . '", "' . $_POST['telephone'] . '", "' . $_POST['email'] . '")';
    mysql_query($sql_contact) or die(mysql_error());

//# commande
    $nb_beneficiares = $_POST['nb_benificaires'];

    $sql_commande = 'INSERT INTO commande(id_etablissement, id_edition, id_abonnement, nb_beneficiares, date_creation) VALUES ("' . $id_etablisssment . '", "' . $_POST['edition'] . '", "' . $_POST['abonnement'] . '", "' . $nb_beneficiares . '", NOW())';
    mysql_query($sql_commande) or die(mysql_error());
    $id_commande = mysql_insert_id();

//# liste bénificiares
    if ($nb_beneficiares == 1) {
        $sql_beneficiare = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare'] . '", "' . $_POST['prenom_beneficiare'] . '", "' . $_POST['fonction_beneficiare'] . '", "' . $_POST['telephone_beneficiare'] . '", "' . $_POST['email_beneficiare'] . '", "' . md5($_POST['mot_passe_beneficiare']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
        mysql_query($sql_beneficiare);
    }

    if ($nb_beneficiares > 1) {
        $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_1'] . '", "' . $_POST['prenom_beneficiare_1'] . '", "' . $_POST['fonction_beneficiare_1'] . '", "' . $_POST['telephone_beneficiare_1'] . '", "' . $_POST['email_beneficiare_1'] . '", "' . md5($_POST['mot_passe_beneficiare_1']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
        mysql_query($sql);

        if (!empty($_POST['nom_beneficiare_2'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_2'] . '", "' . $_POST['prenom_beneficiare_2'] . '", "' . $_POST['fonction_beneficiare_2'] . '", "' . $_POST['telephone_beneficiare_2'] . '", "' . $_POST['email_beneficiare_2'] . '", "' . md5($_POST['mot_passe_beneficiare_2']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_3'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_3'] . '", "' . $_POST['prenom_beneficiare_3'] . '", "' . $_POST['fonction_beneficiare_3'] . '", "' . $_POST['telephone_beneficiare_3'] . '", "' . $_POST['email_beneficiare_3'] . '", "' . md5($_POST['mot_passe_beneficiare_3']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_4'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_4'] . '", "' . $_POST['prenom_beneficiare_4'] . '", "' . $_POST['fonction_beneficiare_4'] . '", "' . $_POST['telephone_beneficiare_4'] . '", "' . $_POST['email_beneficiare_4'] . '", "' . md5($_POST['mot_passe_beneficiare_4']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_5'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_5'] . '", "' . $_POST['prenom_beneficiare_5'] . '", "' . $_POST['fonction_beneficiare_5'] . '", "' . $_POST['telephone_beneficiare_5'] . '", "' . $_POST['email_beneficiare_5'] . '", "' . md5($_POST['mot_passe_beneficiare_5']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_6'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_6'] . '", "' . $_POST['prenom_beneficiare_6'] . '", "' . $_POST['fonction_beneficiare_6'] . '", "' . $_POST['telephone_beneficiare_6'] . '", "' . $_POST['email_beneficiare_6'] . '", "' . md5($_POST['mot_passe_beneficiare_6']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_7'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_7'] . '", "' . $_POST['prenom_beneficiare_7'] . '", "' . $_POST['fonction_beneficiare_7'] . '", "' . $_POST['telephone_beneficiare_7'] . '", "' . $_POST['email_beneficiare_7'] . '", "' . md5($_POST['mot_passe_beneficiare_7']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_8'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_8'] . '", "' . $_POST['prenom_beneficiare_8'] . '", "' . $_POST['fonction_beneficiare_8'] . '", "' . $_POST['telephone_beneficiare_8'] . '", "' . $_POST['email_beneficiare_8'] . '", "' . md5($_POST['mot_passe_beneficiare_8']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_9'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_9'] . '", "' . $_POST['prenom_beneficiare_9'] . '", "' . $_POST['fonction_beneficiare_9'] . '", "' . $_POST['telephone_beneficiare_9'] . '", "' . $_POST['email_beneficiare_9'] . '", "' . md5($_POST['mot_passe_beneficiare_9']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_10'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_10'] . '", "' . $_POST['prenom_beneficiare_10'] . '", "' . $_POST['fonction_beneficiare_10'] . '", "' . $_POST['telephone_beneficiare_10'] . '", "' . $_POST['email_beneficiare_10'] . '", "' . md5($_POST['mot_passe_beneficiare_10']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_11'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_11'] . '", "' . $_POST['prenom_beneficiare_11'] . '", "' . $_POST['fonction_beneficiare_11'] . '", "' . $_POST['telephone_beneficiare_11'] . '", "' . $_POST['email_beneficiare_11'] . '", "' . md5($_POST['mot_passe_beneficiare_11']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_12'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_12'] . '", "' . $_POST['prenom_beneficiare_12'] . '", "' . $_POST['fonction_beneficiare_12'] . '", "' . $_POST['telephone_beneficiare_12'] . '", "' . $_POST['email_beneficiare_12'] . '", "' . md5($_POST['mot_passe_beneficiare_12']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_13'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_13'] . '", "' . $_POST['prenom_beneficiare_13'] . '", "' . $_POST['fonction_beneficiare_13'] . '", "' . $_POST['telephone_beneficiare_13'] . '", "' . $_POST['email_beneficiare_13'] . '", "' . md5($_POST['mot_passe_beneficiare_13']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_14'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_14'] . '", "' . $_POST['prenom_beneficiare_14'] . '", "' . $_POST['fonction_beneficiare_14'] . '", "' . $_POST['telephone_beneficiare_14'] . '", "' . $_POST['email_beneficiare_14'] . '", "' . md5($_POST['mot_passe_beneficiare_14']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_15'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_15'] . '", "' . $_POST['prenom_beneficiare_15'] . '", "' . $_POST['fonction_beneficiare_15'] . '", "' . $_POST['telephone_beneficiare_15'] . '", "' . $_POST['email_beneficiare_15'] . '", "' . md5($_POST['mot_passe_beneficiare_15']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_16'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_16'] . '", "' . $_POST['prenom_beneficiare_16'] . '", "' . $_POST['fonction_beneficiare_16'] . '", "' . $_POST['telephone_beneficiare_16'] . '", "' . $_POST['email_beneficiare_16'] . '", "' . md5($_POST['mot_passe_beneficiare_16']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_17'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_17'] . '", "' . $_POST['prenom_beneficiare_17'] . '", "' . $_POST['fonction_beneficiare_17'] . '", "' . $_POST['telephone_beneficiare_17'] . '", "' . $_POST['email_beneficiare_17'] . '", "' . md5($_POST['mot_passe_beneficiare_17']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_18'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_18'] . '", "' . $_POST['prenom_beneficiare_18'] . '", "' . $_POST['fonction_beneficiare_18'] . '", "' . $_POST['telephone_beneficiare_18'] . '", "' . $_POST['email_beneficiare_18'] . '", "' . md5($_POST['mot_passe_beneficiare_18']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_19'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_19'] . '", "' . $_POST['prenom_beneficiare_19'] . '", "' . $_POST['fonction_beneficiare_19'] . '", "' . $_POST['telephone_beneficiare_19'] . '", "' . $_POST['email_beneficiare_19'] . '", "' . md5($_POST['mot_passe_beneficiare_19']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }

        if (!empty($_POST['nom_beneficiare_20'])) {
            $sql = 'INSERT INTO beneficiare (id_commande, nom, prenom, fonction, telephone, email, password, etablissement, adresse, code_postal, ville) VALUES ("' . $id_commande . '", "' . $_POST['nom_beneficiare_20'] . '", "' . $_POST['prenom_beneficiare_20'] . '", "' . $_POST['fonction_beneficiare_20'] . '", "' . $_POST['telephone_beneficiare_20'] . '", "' . $_POST['email_beneficiare_20'] . '", "' . md5($_POST['mot_passe_beneficiare_20']) . '", "' . $_POST['etablissement'] . '", "' . $_POST['adresse'] . '", "' . $_POST['code_postal'] . '", "' . $_POST['ville'] . '")';
            mysql_query($sql);
        }
    }

    //# date création béneficiares
    $sql_date = 'UPDATE beneficiare SET date_creation = NOW() WHERE id_commande = ' . $id_commande;
    mysql_query($sql_date) or die(mysql_error());

    header("Location:valid_abonnement.php");
    exit();
}


$sql = "SELECT texte FROM texte_abonnements WHERE id = 1";
$req = mysql_query($sql) or die(mysql_error());
$res = mysql_fetch_array($req);

foreach ($res as $key => $val)
    $res[$key] = stripslashes($val);

$texte = $res['texte'];

$sql_abonnement = 'SELECT id, label, prix FROM abonnement';
$req_abonnement = mysql_query($sql_abonnement) or die(mysql_error());

$arr_prix_abonnements = array();
while ($res_abonnement = mysql_fetch_array($req_abonnement)) {
    $arr_prix_abonnements[$res_abonnement['id']]['label'] = $res_abonnement['label'];
    $arr_prix_abonnements[$res_abonnement['id']]['prix'] = $res_abonnement['prix'];
}

$page_index = 3;
?>
<!DOCTYPE html>
<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
        <meta NAME="ROBOTS" CONTENT="INDEX,FOLLOW" />
        <meta name="keywords" content="L'essentiel du sup" />
        <meta NAME="DESCRIPTION" CONTENT="L'essentiel du sup" />
        <link rel="shortcut icon" type="image/x-icon" href="images/favicon.ico" />
        <title>L'essentiel du sup</title>
        <link rel="stylesheet" href="js/validation/css/validationEngine.jquery.css" type="text/css"/>
        <link rel="stylesheet" type="text/css" href="css/style.css" />
        <!--[if IE]>
        <link rel="stylesheet" type="text/css" href="css/ie.css" />
        <![endif]-->
        <script type="text/javascript" src="js/jquery-1.10.2.min.js"></script>
        <script type="text/javascript" src="js/validation/js/languages/jquery.validationEngine-fr.js"></script>
        <script type="text/javascript" src="js/validation/js/jquery.validationEngine.js"></script>
        <script>
            $(function() {
                //# reset form
                $("#form").find(':input').each(function() {
                    switch (this.type) {
                        case 'password':
                        case 'select-multiple':
                        case 'select-one':
                        case 'text':
                        case 'textarea':
                            $(this).val('');
                            break;
                        case 'checkbox':
                        case 'radio':
                            this.checked = false;
                    }
                    $("#prix_total").text("<?php echo $arr_prix_abonnements[1]['prix'] ?>");
                });

                $("#nb_benificaires").change(function() {
                    $("#form").validationEngine('hideAll');
                    var nb_beneficiares = $("#nb_benificaires").val();
                    if ((nb_beneficiares == "") || (nb_beneficiares == 1)) {
                        $("#form_beneficiare_multiselect").hide();
                        $("#form_beneficiare_uniselect").show();
                        $("#prix_total").text("<?php echo $arr_prix_abonnements[1]['prix'] ?>");
                        $("#abonnement").val("1");
                    }
                    if (nb_beneficiares > 1) {
                        $("#form_beneficiare_uniselect").hide();
                        $("#form_beneficiare_multiselect").show();

                        $(".beneficiare-multiselect").hide();

                        for (var i = 1; i <= nb_beneficiares; i++) {
                            $("#form_beneficiare_" + i).show();
                        }

                        switch (parseInt(nb_beneficiares)) {
                            case 2:
                                $("#prix_total").text("<?php echo $arr_prix_abonnements[2]['prix'] ?>");
                                $("#abonnement").val("2");
                                break;
                            case 3:
                                $("#prix_total").text("<?php echo $arr_prix_abonnements[3]['prix'] ?>");
                                $("#abonnement").val("3");
                                break;
                            case 4:
                                $("#prix_total").text("<?php echo $arr_prix_abonnements[4]['prix'] ?>");
                                $("#abonnement").val("4");
                                break;
                            case 5:
                                $("#prix_total").text("<?php echo $arr_prix_abonnements[5]['prix'] ?>");
                                $("#abonnement").val("5");
                                break;
                            case 6:
                                $("#prix_total").text("<?php echo $arr_prix_abonnements[6]['prix'] ?>");
                                $("#abonnement").val("6");
                                break;
                            case 7:
                                $("#prix_total").text("<?php echo $arr_prix_abonnements[7]['prix'] ?>");
                                $("#abonnement").val("7");
                                break;
                            default:
                                $("#prix_total").text("<?php echo $arr_prix_abonnements[8]['prix'] ?>");
                                $("#abonnement").val("8");
                                break;
                        }

                    }
                });

                $("#submit_form").click(function(e) {
                    e.preventDefault();
                    nb_beneficiares = $("#nb_benificaires").val();
                    if ((nb_beneficiares == "") || (nb_beneficiares == 1)) {
                        $("#form_beneficiare_multiselect input").removeClass("validate[required]");

                        $("#form_beneficiare_uniselect #nom_beneficiare").addClass("validate[required]");
                        $("#form_beneficiare_uniselect #prenom_beneficiare").addClass("validate[required]");
                        $("#form_beneficiare_uniselect #fonction_beneficiare").addClass("validate[required]");
                        $("#form_beneficiare_uniselect #telephone_beneficiare").addClass("validate[required,custom[phone]]");
                        $("#form_beneficiare_uniselect #email_beneficiare").addClass("validate[required,custom[email]]");
                        $("#form_beneficiare_uniselect #mot_passe_beneficiare").addClass("validate[required]");
                        $("#form_beneficiare_uniselect #confirm_mot_passe_beneficiare").addClass("validate[required,equals[mot_passe_beneficiare]]");
                        $("#form_beneficiare_uniselect #accepte_beneficiare").addClass("validate[required]");
                    } else {
                        $("#form_beneficiare_uniselect input").removeClass("validate[required]");
                        $("#form_beneficiare_multiselect input").removeClass("validate[required]");
                        for (i = 1; i <= nb_beneficiares; i++) {
                            str = "#form_beneficiare_" + i;

                            $(str + " #nom_beneficiare_" + i).addClass("validate[required]");
                            $(str + " #prenom_beneficiare_" + i).addClass("validate[required]");
                            $(str + " #fonction_beneficiare_" + i).addClass("validate[required]");
                            $(str + " #telephone_beneficiare_" + i).addClass("validate[required,custom[phone]]");
                            $(str + " #email_beneficiare_" + i).addClass("validate[required,custom[email]]");
                            $(str + " #mot_passe_beneficiare_" + i).addClass("validate[required]");
                            $(str + " #confirm_mot_passe_beneficiare_" + i).addClass("validate[required,equals[mot_passe_beneficiare_" + i + "]]");
                            $(str + " #accepte_beneficiare_" + i).addClass("validate[required]");
                        }
                    }

                    $("#form").validationEngine('attach');
                    if ($("#form").validationEngine('validate')) {
                        $("#form").submit();
                    }
                    return false;
                });

                $("#reset_form").click(function() {
                    $("#form").validationEngine('hideAll');
                });
            });
        </script>
    </head>
    <body>
        <div class="main">
            <?php include './inc/header.php'; ?>
            <div class="main-content">
                <div class="main-bloc-1">
                    <div class="left-1">
                        <div class="logo-container">
                            <img src="images/logo.png" alt="L'essentiel du sup" />
                        </div>
                    </div>
                    <div class="right-1">
                        <div class="righ-1-content">
                            <div class="bloc-partage">
                                <!-- AddThis Button BEGIN -->
                                <div class="addthis_toolbox addthis_default_style addthis_32x32_style">
                                    <a class="addthis_button_preferred_1"></a>
                                    <a class="addthis_button_preferred_2"></a>
                                    <a class="addthis_button_preferred_3"></a>
                                    <a class="addthis_button_preferred_4"></a>
                                    <a class="addthis_button_compact"></a>
                                    <a class="addthis_counter addthis_bubble_style"></a>
                                </div>
                                <script type="text/javascript">var addthis_config = {"data_track_addressbar": false};</script>
                                <script type="text/javascript" src="//s7.addthis.com/js/300/addthis_widget.js#pubid=ra-4fe0e68e70742350"></script>
                                <!-- AddThis Button END -->
                            </div>
                        </div>
                    </div>
                </div>
                <div class="main-bloc-full" style="margin-top: 0;">
                    <div class="paragraph">
                        <?php echo $texte ?>
                    </div>
                    <div class="full-bloc-offre">
                        <div class="header-offre">
                            <h2>Offre d’abonnement 1 an de janvier à décembre (soit 42 numéros)</h2>
                        </div>
                        <div class="table-container">
                            <table class="offre-table">
                                <tr>
                                    <th>Nombre de bénéficiaires par institution</th>
                                    <th>Prix annuel de l’abonnement TTC</th>
                                </tr>
                                <?php
                                foreach ($arr_prix_abonnements as $value) {
                                    ?>
                                    <tr>
                                        <td class="td-1"><?php echo $value['label'] ?></td>
                                        <td class="td-2"><?php echo $value['prix'] ?> €</td>
                                    </tr>
                                <?php } ?>
                            </table>
                        </div>
                    </div>
                    <div class="paragraph margin-40">
                        <h2>Formulaire d’abonnement</h2>
                    </div>
                    <div class="full-bloc-offre">
                        <form id="form" class="form-abonnement" action="abonnements.php" method="POST" style="padding-bottom: 30px;">
                            <input type="hidden" name="abonnement" id="abonnement" value="1" />
                            <div class="form-abonnement-content">
                                <div class="form-row">
                                    <label>Etablissement* :</label>
                                    <input class="huge validate[required]" type="text" name="etablissement" id="etablissement" />
                                </div>
                                <div class="form-row">
                                    <table>
                                        <tr>
                                            <td>
                                                <label>Adresse* :</label>
                                                <input class="meduim validate[required]" type="text" name="adresse" id="adresse" />
                                            </td>
                                            <td>
                                                <div style="margin-left: 40px;">
                                                    <label>Code postal* :</label>
                                                    <input class="validate[required]" type="text" name="code_postal" id="code_postal" />
                                                </div>
                                            </td>
                                            <td>
                                                <div style="margin-left: 45px;">
                                                    <label>Ville* :</label>
                                                    <input class="validate[required]" type="text" name="ville" id="ville" />
                                                </div>
                                            </td>
                                        </tr>
                                    </table>
                                </div>
                                <div class="form-row">
                                    <label>Comment avez-vous connu l’Essentiel du sup ? :</label>
                                    <select name="connu_site" id="connu_site" style="width: 360px;">
                                        <option value="">Sélectionner un choix</option>
                                        <option value="1">Par un moteur de recherche</option>
                                        <option value="2">Par un abonné</option>
                                        <option value="3">Par les réseaux sociaux</option>
                                        <option value="4">Par la presse</option>
                                        <option value="5">Par un emailing</option>
                                        <option value="6">Par un contact avec l’équipe de l’Essentiel du sup</option>
                                        <option value="7">Autre</option>
                                    </select>
                                </div>
                                <div class="form-row">
                                    <div class="form-title">
                                        Contact administratif (gestion de l’abonnement et facturation)
                                    </div>
                                </div>
                                <div class="form-row">
                                    <table>
                                        <tr>
                                            <td>
                                                <label>Nom* :</label>
                                                <input class="validate[required]" style="width: 190px;" type="text" name="nom" id="nom" />
                                            </td>
                                            <td>
                                                <div style="margin-left: 40px;">
                                                    <label>Prénom* :</label>
                                                    <input class="validate[required]" style="width: 190px;" type="text" name="prenom" id="prenom" />
                                                </div>
                                            </td>
                                            <td>
                                                <div style="margin-left: 45px;">
                                                    <label>Fonction* :</label>
                                                    <input class="validate[required]" style="width: 190px;" type="text" name="fonction" id="fonction" />
                                                </div>
                                            </td>
                                        </tr>
                                    </table>
                                </div>
                                <div class="form-row">
                                    <table>
                                        <tr>
                                            <td>
                                                <label>Téléphone* :</label>
                                                <input class="validate[custom[phone]]" style="width: 315px;" type="text" name="telephone" id="telephone" />
                                            </td>
                                            <td>
                                                <div style="margin-left: 40px;">
                                                    <label>E-mail* :</label>
                                                    <input class="validate[custom[email]]" style="width: 315px;" type="text" name="email" id="email" />
                                                </div>
                                            </td>
                                        </tr>
                                    </table>
                                </div>
                                <div class="form-row">
                                    <div class="form-title">
                                        Je souhaite créer un ou plusieurs abonnements à l’essentiel du sup
                                    </div>
                                </div>
                                <div class="form-row">
                                    <table>
                                        <tr>
                                            <td>
                                                <label>Édition* :</label>
                                                <select class="validate[required]" name="edition" id="edition" style="width: 360px;">
                                                    <option value="">Sélectionner une édition</option>
                                                    <option value="1">Ecoles de management</option>
                                                    <option value="2">Ecoles d’ingénieurs</option>
                                                    <option value="3">Universités</option>
                                                </select>
                                            </td>
                                            <td>
                                                <div style="margin-left: 40px;">
                                                    <label>Nombre de bénéficiaires* :</label>
                                                    <select class="validate[required]" name="nb_benificaires" id="nb_benificaires" style="width: 200px;">
                                                        <option value="">Nombre de bénificiares</option>
                                                        <option value="1">1</option>
                                                        <option value="2">2</option>
                                                        <option value="3">3</option>
                                                        <option value="4">4</option>
                                                        <option value="5">5</option>
                                                        <option value="6">6</option>
                                                        <option value="7">7</option>
                                                        <option value="8">8</option>
                                                        <option value="9">9</option>
                                                        <option value="10">10</option>
                                                        <option value="12">11</option>
                                                        <option value="13">13</option>
                                                        <option value="14">14</option>
                                                        <option value="15">15</option>
                                                        <option value="16">16</option>
                                                        <option value="17">17</option>
                                                        <option value="18">18</option>
                                                        <option value="19">19</option>
                                                        <option value="20">20</option>
                                                    </select>
                                                </div>
                                            </td>
                                        </tr>
                                    </table>
                                </div>
                                <div id="form_beneficiares_container">
                                    <div id="form_beneficiare_uniselect">
                                        <div class="form-row">
                                            <div class="form-title">
                                                Bénéficiaire
                                            </div>
                                        </div>
                                        <div class="form-row">
                                            <table>
                                                <tr>
                                                    <td>
                                                        <label>Nom* :</label>
                                                        <input class="text" style="width: 190px;" type="text" name="nom_beneficiare" id="nom_beneficiare" />
                                                    </td>
                                                    <td>
                                                        <div style="margin-left: 40px;">
                                                            <label>Prénom* :</label>
                                                            <input class="text" style="width: 190px;" type="text" name="prenom_beneficiare" id="prenom_beneficiare" />
                                                        </div>
                                                    </td>
                                                    <td>
                                                        <div style="margin-left: 45px;">
                                                            <label>Fonction* :</label>
                                                            <input class="text" style="width: 190px;" type="text" name="fonction_beneficiare" id="fonction_beneficiare" />
                                                        </div>
                                                    </td>
                                                </tr>
                                            </table>
                                        </div>
                                        <div class="form-row">
                                            <table>
                                                <tr>
                                                    <td>
                                                        <label>Téléphone* :</label>
                                                        <input class="telephone" style="width: 315px;" type="text" name="telephone_beneficiare" id="telephone_beneficiare" />
                                                    </td>
                                                    <td>
                                                        <div style="margin-left: 40px;">
                                                            <label>E-mail* :</label>
                                                            <input class="email" style="width: 315px;" type="text" name="email_beneficiare" id="email_beneficiare" />
                                                        </div>
                                                    </td>
                                                </tr>
                                            </table>
                                        </div>
                                        <div class="form-row">
                                            <table>
                                                <tr>
                                                    <td>
                                                        <label>Mot de passe* :</label>
                                                        <input class="text" type="password" style="width: 315px;" type="password" name="mot_passe_beneficiare" id="mot_passe_beneficiare" />
                                                    </td>
                                                    <td>
                                                        <div style="margin-left: 40px;">
                                                            <label>Confirmation du mot de passe* :</label>
                                                            <input class="password" type="password" style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare" id="confirm_mot_passe_beneficiare" />
                                                        </div>
                                                    </td>
                                                </tr>
                                            </table>
                                        </div>
                                        <div class="form-row" style="margin-top: 5px;">
                                            <input class="text" type="checkbox" name="accepte_beneficiare" id="accepte_beneficiare" />
                                            <label style="margin-left: 1px; display: inline;">
                                                Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                            </label>
                                        </div>
                                    </div>
                                    <div id="form_beneficiare_multiselect" class="hide">
                                        <div id="form_beneficiare_1" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 1
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_1" id="nom_beneficiare_1" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_1" id="prenom_beneficiare_1" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_1" id="fonction_beneficiare_1" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_1" id="telephone_beneficiare_1" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_1" id="email_beneficiare_1" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_1" id="mot_passe_beneficiare_1" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_1" id="confirm_mot_passe_beneficiare_1" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_1" id="accepte_beneficiare_1" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_2" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 2
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_2" id="nom_beneficiare_2" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_2" id="prenom_beneficiare_2" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_2" id="fonction_beneficiare_2" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_2" id="telephone_beneficiare_2" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_2" id="email_beneficiare_2" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_2" id="mot_passe_beneficiare_2" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_2" id="confirm_mot_passe_beneficiare_2" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_2" id="accepte_beneficiare_2" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_3" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 3
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_3" id="nom_beneficiare_3" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_3" id="prenom_beneficiare_3" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_3" id="fonction_beneficiare_3" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_3" id="telephone_beneficiare_3" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_3" id="email_beneficiare_3" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_3" id="mot_passe_beneficiare_3" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_3" id="confirm_mot_passe_beneficiare_3" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_3" id="accepte_beneficiare_3" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_4" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 4
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_4" id="nom_beneficiare_4" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_4" id="prenom_beneficiare_4" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_4" id="fonction_beneficiare_4" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_4" id="telephone_beneficiare_4" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_4" id="email_beneficiare_4" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_4" id="mot_passe_beneficiare_4" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_4" id="confirm_mot_passe_beneficiare_4" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_4" id="accepte_beneficiare_4" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_5" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 5
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_5" id="nom_beneficiare_5" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_5" id="prenom_beneficiare_5" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_5" id="fonction_beneficiare_5" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_5" id="telephone_beneficiare_5" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_5" id="email_beneficiare_5" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_5" id="mot_passe_beneficiare_5" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_5" id="confirm_mot_passe_beneficiare_5" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_5" id="accepte_beneficiare_5" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_6" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 6
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_6" id="nom_beneficiare_6" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_6" id="prenom_beneficiare_6" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_6" id="fonction_beneficiare_6" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_6" id="telephone_beneficiare_6" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_6" id="email_beneficiare_6" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_6" id="mot_passe_beneficiare_6" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_6" id="confirm_mot_passe_beneficiare_6" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_6" id="accepte_beneficiare_6" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_7" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 7
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_7" id="nom_beneficiare_7" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_7" id="prenom_beneficiare_7" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_7" id="fonction_beneficiare_7" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_7" id="telephone_beneficiare_7" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_7" id="email_beneficiare_7" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_7" id="mot_passe_beneficiare_7" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_7" id="confirm_mot_passe_beneficiare_7" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_7" id="accepte_beneficiare_7" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_8" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 8
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_8" id="nom_beneficiare_8" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_8" id="prenom_beneficiare_8" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_8" id="fonction_beneficiare_8" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_8" id="telephone_beneficiare_8" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_8" id="email_beneficiare_8" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_8" id="mot_passe_beneficiare_8" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_8" id="confirm_mot_passe_beneficiare_8" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_8" id="accepte_beneficiare_8" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_9" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 9
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_9" id="nom_beneficiare_9" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_9" id="prenom_beneficiare_9" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_9" id="fonction_beneficiare_9" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_9" id="telephone_beneficiare_9" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_9" id="email_beneficiare_9" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_9" id="mot_passe_beneficiare_9" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_9" id="confirm_mot_passe_beneficiare_9" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_9" id="accepte_beneficiare_9" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_10" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 10
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_10" id="nom_beneficiare_10" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_10" id="prenom_beneficiare_10" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_10" id="fonction_beneficiare_10" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_10" id="telephone_beneficiare_10" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_10" id="email_beneficiare_10" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_10" id="mot_passe_beneficiare_10" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_10" id="confirm_mot_passe_beneficiare_10" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_10" id="accepte_beneficiare_10" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_11" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 11
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_11" id="nom_beneficiare_11" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_11" id="prenom_beneficiare_11" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_11" id="fonction_beneficiare_11" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_11" id="telephone_beneficiare_11" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_11" id="email_beneficiare_11" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_11" id="mot_passe_beneficiare_11" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_11" id="confirm_mot_passe_beneficiare_11" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_11" id="accepte_beneficiare_11" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_12" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 12
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_12" id="nom_beneficiare_12" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_12" id="prenom_beneficiare_12" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_12" id="fonction_beneficiare_12" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_12" id="telephone_beneficiare_12" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_12" id="email_beneficiare_12" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_12" id="mot_passe_beneficiare_12" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_12" id="confirm_mot_passe_beneficiare_12" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_12" id="accepte_beneficiare_12" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_13" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 13
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_13" id="nom_beneficiare_13" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_13" id="prenom_beneficiare_13" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_13" id="fonction_beneficiare_13" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_13" id="telephone_beneficiare_13" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_13" id="email_beneficiare_13" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_13" id="mot_passe_beneficiare_13" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_13" id="confirm_mot_passe_beneficiare_13" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_13" id="accepte_beneficiare_13" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_14" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 14
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_14" id="nom_beneficiare_14" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_14" id="prenom_beneficiare_14" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_14" id="fonction_beneficiare_14" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_14" id="telephone_beneficiare_14" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_14" id="email_beneficiare_14" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_14" id="mot_passe_beneficiare_14" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_14" id="confirm_mot_passe_beneficiare_14" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_14" id="accepte_beneficiare_14" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_15" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 15
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_15" id="nom_beneficiare_15" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_15" id="prenom_beneficiare_15" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_15" id="fonction_beneficiare_15" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_15" id="telephone_beneficiare_15" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_15" id="email_beneficiare_15" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_15" id="mot_passe_beneficiare_15" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_15" id="confirm_mot_passe_beneficiare_15" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_15" id="accepte_beneficiare_15" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_16" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 16
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_16" id="nom_beneficiare_16" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_16" id="prenom_beneficiare_16" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_16" id="fonction_beneficiare_16" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_16" id="telephone_beneficiare_16" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_16" id="email_beneficiare_16" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_16" id="mot_passe_beneficiare_16" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_16" id="confirm_mot_passe_beneficiare_16" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_16" id="accepte_beneficiare_16" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_17" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 17
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_17" id="nom_beneficiare_17" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_17" id="prenom_beneficiare_17" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_17" id="fonction_beneficiare_17" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_17" id="telephone_beneficiare_17" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_17" id="email_beneficiare_17" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_17" id="mot_passe_beneficiare_17" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_17" id="confirm_mot_passe_beneficiare_17" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_17" id="accepte_beneficiare_17" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_18" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 18
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_18" id="nom_beneficiare_18" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_18" id="prenom_beneficiare_18" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_18" id="fonction_beneficiare_18" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_18" id="telephone_beneficiare_18" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_18" id="email_beneficiare_18" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_18" id="mot_passe_beneficiare_18" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_18" id="confirm_mot_passe_beneficiare_18" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_18" id="accepte_beneficiare_18" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_19" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 19
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_19" id="nom_beneficiare_19" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_19" id="prenom_beneficiare_19" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_19" id="fonction_beneficiare_19" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_19" id="telephone_beneficiare_19" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_19" id="email_beneficiare_19" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_19" id="mot_passe_beneficiare_19" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_19" id="confirm_mot_passe_beneficiare_19" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_19" id="accepte_beneficiare_19" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                        <div id="form_beneficiare_20" class="beneficiare-multiselect">
                                            <div class="form-row">
                                                <div class="form-title">
                                                    Bénéficiaire 20
                                                </div>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Nom* :</label>
                                                            <input style="width: 190px;" type="text" name="nom_beneficiare_20" id="nom_beneficiare_20" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Prénom* :</label>
                                                                <input style="width: 190px;" type="text" name="prenom_beneficiare_20" id="prenom_beneficiare_20" />
                                                            </div>
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 45px;">
                                                                <label>Fonction* :</label>
                                                                <input style="width: 190px;" type="text" name="fonction_beneficiare_20" id="fonction_beneficiare_20" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Téléphone* :</label>
                                                            <input style="width: 315px;" type="text" name="telephone_beneficiare_20" id="telephone_beneficiare_20" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>E-mail* :</label>
                                                                <input style="width: 315px;" type="text" name="email_beneficiare_20" id="email_beneficiare_20" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row">
                                                <table>
                                                    <tr>
                                                        <td>
                                                            <label>Mot de passe* :</label>
                                                            <input style="width: 315px;" type="password" name="mot_passe_beneficiare_20" id="mot_passe_beneficiare_20" />
                                                        </td>
                                                        <td>
                                                            <div style="margin-left: 40px;">
                                                                <label>Confirmation du mot de passe* :</label>
                                                                <input style="width: 315px;" type="password" name="confirm_mot_passe_beneficiare_20" id="confirm_mot_passe_beneficiare_20" />
                                                            </div>
                                                        </td>
                                                    </tr>
                                                </table>
                                            </div>
                                            <div class="form-row" style="margin-top: 5px;">
                                                <input type="checkbox" name="accepte_beneficiare_20" id="accepte_beneficiare_20" />
                                                <label style="margin-left: 1px; display: inline;">
                                                    Conformément au code sur la propriété intellectuelle, je m’engage à ne jamais reproduire, transmettre ou partager cette lettre, sauf accord formel de HEADway*
                                                </label>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="form-row">
                                    <div class="form-title"> Règlement </div>
                                </div>
                                <div class="form-row">
                                    <label>Prix annuel de votre abonnement : <span id="prix_total"></span> €<br/>
                                        Le montant à régler pour l’année en cours vous sera confirmé par mail selon le devis ou le bon de commande convenu avec HEADway.</label>
                                </div>
                                <div class="form-row">
                                    <label>Je souhaite régler :</label>
                                    <input type="radio" class="validate[required]" value="1" id="mode_paiement_cheque" name="mode_paiement">
                                    <label style="margin-left: 1px; display: inline;"> Par chèque à l’ordre de HEADway </label><br/>
                                    <input type="radio" class="validate[required]" value="2" id="mode_paiement_virement" name="mode_paiement">
                                    <label style="margin-left: 1px; display: inline;"> Par virement bancaire BNP PARIBAS - FR76 3000 4008 2500 0101 2981 571 / BIC : BNPAFRPPPAK </label>
                                </div>
                                <div class="form-row" style="margin-top: 10px;">
                                    <input class="validate[required]" type="checkbox" id="accepte_conditions" name="accepte_conditions">
                                    <label style="margin-left: 1px; display: inline;"> J´ai lu et j´accepte les conditions générales de vente. <a href="#" style="color: #000">Voir</a> </label>
                                </div>
                                <div class="form-row">
                                    <button type="submit" name="submit_form" id="submit_form">Enregistrer</button>
                                </div>
                            </div>
                        </form>
                    </div>
                    <div style="margin: 20px 20px;">
                        <p style="font-size: 12px;">
                            <strong>Protection des données</strong><br/><br/>
                            Votre adresse email est traitée confidentiellement et n’est utilisée que pour les informations envoyées par HEADway. Vos informations sont enregistrées de manière codée et ne sont PAS transmises à des tiers. Conformément à la Loi Informatique et Liberté, vous bénéficiez d’un droit d’accès, de modification ou de suppression des données vous concernant. Pour l’exercer, merci de nous contacter par mail <a href="mailto:lessentiel@headway-advisory.com">ici</a>.
                        </p>
                    </div>
                </div>
            </div>
            <?php include './inc/footer.php'; ?>
        </div>
    </body>
</html>